Psychiatry and Primary CareEvaluation of a mental health training intervention for multidisciplinary teams in primary care in Brazil: a pre- and posttest study
Introduction
Mental disorders are common in the community and associated with high levels of burden and with communicable and noncommunicable diseases [1], [2], [3]. The World Health Organization highlights the importance of integrating mental health care into primary health care as the optimal strategy for addressing this burden [4], [5]. However, there is a marked underdiagnosis of mental disorders in primary care [6], [7], [8], [9]. Training programs have shown limited evidence of effectiveness [10], [11], but more complex education strategies, particularly involving better integration with mental health specialists, may be more likely to achieve a biopsychosocial approach and may be more effective in encouraging behavior change [4], [12], [13], [14], [15], [16]. Many strategies to achieve an effective collaboration between primary care staff and mental health specialists have been developed ranging from collaborative to shared care models with different impacts on primary and secondary care integration [17], [18], [19], [20], [21], [22].
There is a growing impetus in Brazil towards development of primary health care [23], [24], [25] and the reorganization of mental health services [26]. In less than 20 years, more than 30,000 primary care teams [general practitioners (GPs), nurses, nurse assistants and community workers] have been introduced. The Brazilian Government has also been promoting a progressive substitution of psychiatric hospitals for community psychosocial centers and encouraging long-stay patients to leave hospital and return to the community. Additionally, specific teams to support primary care professionals were launched. This has led to introduction of a shared care model (matrix support) between primary care and mental health teams to promote continuing education in mental health for primary care staff and better integration between these public health services.
It is expected that promoting this shared care model will help primary care and mental health teams improve communication to support patient-centered care, increase the recognition of mental health problems, develop appropriate shared care models for complex problems, improve community engagement and improve the appropriateness of referrals to specialist care. Some evidence has shown that effective interaction is crucial for integrated care [27], [28], although there is more limited evidence on effectiveness in improving patient outcomes [14], [29]. We have developed a training program to improve collaboration between primary care and mental health in Brazil.
The aims of this study are to:
- 1.
Assess the impact of training in a shared care model on the recognition of mental health problems by primary care doctors and nurses (primary outcome);
- 2.
Assess the impact of training in a shared care model on patient-centered care, shared care and referrals by primary care doctors and nurses (secondary outcomes).
To our knowledge, this is the first research evaluation of shared care training in primary care mental health in Brazil.
Section snippets
The training intervention
The training was composed of six seminars each divided into two sessions, combined with eight practical clinical rounds in the primary care setting. The total length of the training was 96 h over 10–12 weeks. Primary care doctors and nurses, social workers, psychologists, psychiatrists and occupational therapists received the training in groups of 40. The seminar sessions were mainly based on workshops in which a number of role plays took place in line with the training content (Table 1). The
Data analysis
The primary outcome was the effect of the training on the ability of the primary health care professionals to recognize mental health problems. Data on the pro forma were compared with patient GHQ scores. Any psychiatric disorder or emotional complaint registered by the doctor or nurse was considered ‘positive’ in terms of recognition. The detection rate was calculated as shown in Table 2.
The overall detection rate across all professionals was compared before and after training using a z test
Sample characteristics
Six classes were performed across the 4 cities with 240 professionals involved, and 47 professionals from primary care participated. The training program was successfully delivered with 36/47 primary care professionals (77%) completing the course. However, only 21 primary care professionals (45%) completed the research study as depicted in Fig. 1. Most of the professionals who participated in the study had not been formally trained in family practice and have little experience with mental
Summary of the results
Overall, our results showed that a 96-h multifaceted training intervention for primary care and mental health workers did not provide consistent benefit in the recognition on mental health problems. Secondary analyses did provide some evidence of differing patterns of results in different professional groups. The nurses increased their ability to recognize mental disorder. In terms of secondary outcomes, only the patient-centered care approach improved, with no change in other processes of care.
Conclusion
The training intervention to promote shared care was not effective in changing recognition and management behavior of primary care professionals in routine practice. Although some impact was observed in nurses, these secondary analyses need replication. Given the profound changes that the Brazilian health system has been promoting in both primary health care and mental health services, it is critical to better understand barriers to integration and promote more effective collaboration between
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